Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

a new day
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2016 is literally around the corner, leaving me with 18 months to
retirement. Its with a mixture of trepidation, expectation and hope that I
turn the page....

1 year ago

Thursday, October 8, 2009

New Vital Signs

Medical tradition has held that there are four vital signs. They are the pulse count, respiration rate, blood pressure, and temperature. While nobody’s asked me, I presume they are called vital signs because, with the possible exception of popsicles like Walt Disney, Ted Williams, and the crew of the SS Botany Bay (KHHAAANNNN!), one simply cannot be vital without them.

Even now, the measurement and interpretation of vital signs remains one of the most important aspects of clinical care. One of the cardinal rules of Emergency Medicine is that you can’t send a patient home unless you can explain or correct any abnormal vital signs. Vitals signs also serve as the miser’s lab test, a low-tech, no cost indicator of patient status. It is to the detriment of medical practice and art that in our hurry to build volume and bill technology, vital signs are either neglected or cursorily acquired without any of the real-world interpretation encompassed in actual patient observation. Vital signs help to interpret patient complaints; it’s hard to assess a patient who says they have a fever when no temperature was ever taken (an unfortunate side effect of many “no wait” ED triage systems). Similarly, careful assessment of vital signs and matching them with the clinical status of the patient is something technology cannot achieve without human interpretation. It would good to know if the patient is cool and clammy because they’ve just been in the pool or their blood pressure is zero. (Admittedly, that last one was hyperbole. The fact is that when you have no blood pressure, the sweating stops. As does your pulse, your respirations, your ability to think at a level higher than Jessica Simpson, and most other things we associate with life. It's a corollary to that wonderful surgical rule that reads "All Bleeding Stops. Eventually.")

But modern medicine, just like the Value Meal at McDonald’s, is all about more. If four vital signs were good, five must be better. And so about thirty years ago it became popular to add the Glasgow Coma Score (GCS) to the hoary hierarchy of health. In brief, the GCS is a measure of neurologic status based on eye opening, verbal response, and the ability to move the limbs to stimuli. The score ranges from 3 to 15, three being a comatose state and 15 being awake, alert, oriented, and able to say things like "it's important that we engage in constructive dialogue with the Iranian leaders" without laughing (oh, wait..maybe I got it reversed).

The GCS is actually a very cool invention, one about which I have waxed, if not eloquently at least pedantically, in some previous work for jems.com. However, what I’ve always found most fun about the GCS is that if there is no response to a measured parameter, there is a natural assumption that the score should be zero rather than one. It’s nobody’s fault…nothing equals zero in most other facets of life, so it’s a deeply ingrained pattern of behavior. But the GCS doesn’t work that way, which is why from time to time you’ll get a call from a paramedic indicating that the GCS is 0, which as far as I can tell is better than dead.

For the last decade it’s been in vogue to add pain to the list as well. This idea is based on work documenting that physicians often undertreated pain. In addition, pain became one of the criteria by which a patient must receive an emergency evaluation and stabilization exam under the tenets of federal EMTALA (Emergency Medical Treatment and Active Labor Act) legislation. Pain control then became a rallying cry for patient’s rights organizations, often to the extent that the idea of clinically appropriate pain control was turned on its head. At one point during my tenure as Kansas State Health Director, there was even a bill put up before the legislature with a clause that would require physicians to treat a patient’s pain in a manner best determined by the patient, not the physician. That's not a bad idea if patients have terminal cancer, who in my book are entitled to any medication they want. But it's not a good idea if the law is intended to satisfy patient demands regardless of need.

(I could write any number of other pieces on this blog about how we deal with drug seekers, in the ED. I know some of my colleagues get frustrated by them, but dealing with these patients for me is a game of Clue in real time, my own personal version of CSI. There is the part where you do your clinical job, ferreting out behavioral and exam clues as to the true nature and severity of pain; there is the part where you check out the story and gather other background materials through phone calls and old records; and finally there is the moment when you synthesize the data, open the envelope with the cards, and declare the case solved.

I won’t go into great details about how ED docs do this for fear of giving away some of our deductive powers. But let me simply offer this single point of advice: We know where the telephone is and we know how to use it.)

The cunning linguists among you (always wanted to work this line in somewhere) will note that a sign is an objective finding, while a symptoms is a subjective sensation. This definitional problem has led to the creation of a number of pain scales in an attempt to standardize an inherently variant phenomenon.

The most interesting are those that ask the patient to rate the pain on a scale from one to ten. One of these scales notes that a pain level of ten is the worst pain you can imagine. This scale appeals to the philosopher in me. If you can imagine something, then you can imagine something greater, and imagination is by definition infinite. So according to this scale, no pain can ever reach ten, because you could always imagine just a bit more pain than you have, and then you can imagine just a bit more pain than that. It’s the same paradox that has Zeno’s tortoise winning the race no matter how fast Achilles could run and how little the head start.

Then there are the scales that establish ten as the level at which you would do yourself bodily harm to be rid of the pain. If that’s the case, then instead of using drugs for pain relief the most cost-effective way to handle the problem would seem to be an informed consent for euthanasia. (But I hate taking business from Dr. Kevorkian.) The scales that are the most fun are those that establish ten as pain so bad you’re unconscious, because when the malingering patient says to me they have a pain level of 10 I can look at them and say, without judgment or malice, that they’re lying because they’re still talking and not unconscious (in which case you don’t have any pain, right?).

I’ve been thinking about vital signs lately because last week I thought I had stumbled on the Next Big Thing in Vitals. It was The Moan. In the ED one hears a lot of patient noises, and it’s important to be able to distinguish between those sounds which suggest a person in distress and those which indicate your life is about to become difficult. So as the ambulance brought in a young woman whose moans suggested the latter was to be my immediate fate, I wondered if volume, pitch, or frequency of the moan could be used as an index of illness severity. My initial hypothesis was the volume of the moan was inversely proportional to the degree of acute pathology; the louder you yell, the better your lungs and heart and the less likely you are to actually require emergency care. (Actually, when I initially thought of this I wasn’t using such polite terms. My train of thought was less clinical and much more directed at the assumed personality characteristics of the said producer of the industrial-strength holler. But I’m sure you get the drift.)

I ran this idea by a wise, weather-beaten colleague of mine, the kind of guy who doesn't recognize narcotics more potent than two fingers of Jack and an old poster of Farah Fawcett. He quite rightly suggested that moaning in and of itself was a non-specific indicator with poor specificity, sensitivity, and predictive values. (And they say there's no academic talk in community hospitals. Look at all those big words, huh?) He pointed out that many patients have a perfectly valid reason to moan and probably ought to be allowed to do so without fear of labeling. Folks with kidney stones, for instance, should and do moan. People with mangled limbs are not only expected to moan, but have the God-given right to do so. Patients with acute cardiac events may also moan to themselves as they briefly reflect upon their lives (those who rise up out of bed and shout, "Elizabeth! I'm comin', honey!" are a different matter entirely). So if I was going to pursue this line of reasoning and develop a powerful clinical tool, clearly more thought was required.

I started to reflect on other markers that might contribute to my new index of patient non-distress. For example, three weeks ago the ambulance brought us a young woman who was dying. We knew she was dying because she would emerge from her exam room, stride up to the nurse's desk, loudly proclaim “I’M DYING” while asking for pain medication, and saunter back to her room until the next matinee 2.83 minutes later (6 episodes in 17 minutes...yes, it was timed). When I finally had an opportunity to visit with the patient (after seeing two other patients who were not only not moaning, but not breathing as well) I discussed with her that I felt comfortable saying that she was actually not dying because those who usually are often do so quietly and seldom make a habit of getting up and notifying us of their impending demise. So perhaps one of the parameters for my new vital sign should be related to the number of times you walk away from your bed to tell the nurse of your imminent discharge to the celestial floor.

A third thing I want to fit in is the number of previous visits to the ED. In general, those who use the ED more frequently tend to have less severe illness on presentation. (Again I’m using polite language here, although in person I will often ask our “Frequent Flyers” if they’re getting companion tickets for their dozen visits this year alone. But to show you how medicine has evolved, twenty years ago when I started I would ask they were getting Green Stamps.)

By themselves, none of these parameters meets the level of significance needed for a valid clinical measure. We’ve already mentioned that there are entirely valid reasons for moaning, and there are some truly unfortunate people with terrible progressive disease who do require frequent ED visits. So in order to make this work, combining the measures into a single equation seems to have the best chance of providing an accurate measure of patient non-severity. So as of 5:47 tonight, here’s my winning entry:

(Decibel volume of moaning) x(Nursing desk visits for death proclamations) x(Number of previous ED visits in past 24 months for same complaint) =Non-Severity of Non-Illness Index (NSNII, or The "Rodenberg Score")

(You may have noticed that even in the few pieces I've already submitted to this blog, I keep naming stuff after myself. There are two main reasons for this. The first is that, like Beowulf, a large part of me believes the way you survive after death is through the fame you've achieved in life. In medicine, fame is to be an eponym. The other reason is that the only thing that ever actually got named after me was a local EMS prehospital seizure treatment protocol that used rectal valium, a procedure that came to be known as a "Rodenberg ." I would much rather have my name covered with some other form of glory than...ummm...sheizure.)

Like most things in medicine, a few caveats must be kept in mind. The score cannot be applied to children less than 12, because you simply can't choose your parents. (One of the saddest things I know is to see bright and happy little kids in the ED, and then look at their family and realize the child has no chance in life.) And it’s also considered invalid in nursing home patients, because tradition dictates that they be shipped out to the ED every time they roll over in their beds, accidentally pinning the remote under their hip and turning off The Real Housewives of Beverly Hills during shift change. (And there are three shifts each day.)

I look forward to your help with this research effort. Additional contributions are welcome. But it'll still be called The Rodenberg Score. Just so we're clear on that.